UWORLD NCLEX (2024-2025) QUESTIONS WITH
ANSWERS
The nurse is caring for a client who has undergone a
craniotomy and has a supratentorial incision. The nurse
should place the client in which position postoperatively?
1. Head of bed flat, head and neck midline.
2. Head of bed flat, head turned to the nonoperative side
3. Head of bed elevated 30 to 45 degrees, head and neck
midline
4. Head of bed elevated 30 to 45 degrees, head turned to the
operative side - _answers___3
After a supratentorial surgery, the head is kept at a 30-45
degree angle. The head and neck should not be angled either
anteriorly or laterally but rather should be kept in a neutral
(midline) position. This promotes venous return through the
jugular veins, which will help prevent a rise in intracranial
pressure.
A client is admitted to the hospital for severe headaches. The
client has a history of increased intracranial pressure (icp),
which has required lumbar punctures to relieve the pressure
by draining cerebrospinal fluid. The client suddenly vomits
and states, "that's weird, i didn't even feel nauseated." which
action by the nurse is the most appropriate?
1. Document the amount of emesis
2. Lower the head of the bed
3. Notify the health care provider (hcp)
, UWORLD NCLEX (2024-2025) QUESTIONS WITH
ANSWERS
4. Offer anti-nausea medication - _answers___3
Unexpected and projectile vomiting without nausea can be a
sign of increased icp, especially in the client with a history of
increased icp. The unexpected vomiting is related to pressure
changes in the cranium. The vomiting can be associated with
headache and gets worse with lowered head position. The
most appropriate action is to obtain a full set of vital signs and
contact the hcp immediately.
(option 1) documentation is important, but it is not the priority
action.
(option 2) the head of the bed should be raised, not lowered,
for clients with suspected increased icp. Raising the head of
the bed to 30 degrees helps to drain the cerebrospinal fluid via
the valve system without lowering the cerebral blood
pressure.
(option 4) the vomiting is caused not by nausea but by
pressure changes in the cranium. Anti-nausea medications are
often not effective. Decreasing intracranial pressure will help
the vomiting.
Educational objective:
Notify the hcp of signs/symptoms of increased icp, including
unexpected vomiting. The vomiting is often projectile,
, UWORLD NCLEX (2024-2025) QUESTIONS WITH
ANSWERS
associated with headache, and gets worse with lowering the
head position.
The nurse is caring for a client after a motor vehicle accident.
The client's injuries include 2 fractured ribs and a concussion.
The nurse notes which of the following as expected
neurological changes for the client with a concussion? Select
all that apply.
1. Asymmetrical pupillary constriction
2. Brief loss of consciousness
3. Headache
4. Loss of vision
5. Retrograde amnesia - _answers___2, 3, 5
A concussion is considered a minor traumatic brain injury and
results from blunt force or an acceleration/deceleration head
injury. Typical signs of concussion include:
A brief disruption in level of consciousness
Amnesia regarding the event (retrograde amnesia)
Headache
These clients should be observed closely by family members
and not participate in strenuous or athletic activities for 1-2
days. Rest and a light diet are encouraged during this time.
ANSWERS
The nurse is caring for a client who has undergone a
craniotomy and has a supratentorial incision. The nurse
should place the client in which position postoperatively?
1. Head of bed flat, head and neck midline.
2. Head of bed flat, head turned to the nonoperative side
3. Head of bed elevated 30 to 45 degrees, head and neck
midline
4. Head of bed elevated 30 to 45 degrees, head turned to the
operative side - _answers___3
After a supratentorial surgery, the head is kept at a 30-45
degree angle. The head and neck should not be angled either
anteriorly or laterally but rather should be kept in a neutral
(midline) position. This promotes venous return through the
jugular veins, which will help prevent a rise in intracranial
pressure.
A client is admitted to the hospital for severe headaches. The
client has a history of increased intracranial pressure (icp),
which has required lumbar punctures to relieve the pressure
by draining cerebrospinal fluid. The client suddenly vomits
and states, "that's weird, i didn't even feel nauseated." which
action by the nurse is the most appropriate?
1. Document the amount of emesis
2. Lower the head of the bed
3. Notify the health care provider (hcp)
, UWORLD NCLEX (2024-2025) QUESTIONS WITH
ANSWERS
4. Offer anti-nausea medication - _answers___3
Unexpected and projectile vomiting without nausea can be a
sign of increased icp, especially in the client with a history of
increased icp. The unexpected vomiting is related to pressure
changes in the cranium. The vomiting can be associated with
headache and gets worse with lowered head position. The
most appropriate action is to obtain a full set of vital signs and
contact the hcp immediately.
(option 1) documentation is important, but it is not the priority
action.
(option 2) the head of the bed should be raised, not lowered,
for clients with suspected increased icp. Raising the head of
the bed to 30 degrees helps to drain the cerebrospinal fluid via
the valve system without lowering the cerebral blood
pressure.
(option 4) the vomiting is caused not by nausea but by
pressure changes in the cranium. Anti-nausea medications are
often not effective. Decreasing intracranial pressure will help
the vomiting.
Educational objective:
Notify the hcp of signs/symptoms of increased icp, including
unexpected vomiting. The vomiting is often projectile,
, UWORLD NCLEX (2024-2025) QUESTIONS WITH
ANSWERS
associated with headache, and gets worse with lowering the
head position.
The nurse is caring for a client after a motor vehicle accident.
The client's injuries include 2 fractured ribs and a concussion.
The nurse notes which of the following as expected
neurological changes for the client with a concussion? Select
all that apply.
1. Asymmetrical pupillary constriction
2. Brief loss of consciousness
3. Headache
4. Loss of vision
5. Retrograde amnesia - _answers___2, 3, 5
A concussion is considered a minor traumatic brain injury and
results from blunt force or an acceleration/deceleration head
injury. Typical signs of concussion include:
A brief disruption in level of consciousness
Amnesia regarding the event (retrograde amnesia)
Headache
These clients should be observed closely by family members
and not participate in strenuous or athletic activities for 1-2
days. Rest and a light diet are encouraged during this time.
